Membership Form - Kings Hammer Academy
Kentucky Youth Soccer Membership Form
League Name
Age Group
FOR LEAGUE USE ONLY TRANSFER NEW REREGISTRATION CHANGE/CORRECTION
Div. National Assoication of the United States Soccer Federation (USSF) Affiliated with the Federation Internationale de Football Association (FIFA)
Club/Team Name(s)
Recreational = R Select = S
Last Name
First Name
ID#
Init.
Address
City
State
Zip Code
Area Code
Telephone Number
Father's Name
Male = M Female = F
Month Day Year Birthdate
Occupation
Player = P Coach = C
Coach's License level
Bus. Phone Optional
Mother's Name
Occupation
Bus. Phone Optional
List any medical problem or prohibition player has Person to notify in emergency
Telephone
Doctor to notify in emergency Number prior seasons played
Last Team
Height
Weight
Telephone Date and Year of Last Season
Last League School
Grade
UNIFORM SIZE XS
S
M
Age
Adult
Youth L
XL
XS
S
M
L
XL
SHIRTS: SHORTS:
Other Children From Family Presently In League
Age Age Age
SOCKS:
Age
IMPORTANT I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of US Youth Soccer, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the US Youth Soccer accepting the registrant for its soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. Name
PARENTAL SUPPORT We ask for active participation of all parents in our program. Check area(s) in which you would be willing to help. Coach Committee
Parent/Legal Guardian (please print)
Signature
Date
Asst. Coach Team Manager Team Parent
Referee Fund Raising Clerical
Special Projects Field Preparation
Reporter Newsletter
Board Member
Concessions
Publicity
Donor
Other
CONSENT FOR MEDICAL TREATMENT (MINOR) As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
OFFICIAL USE ONLY
Picture Received
Yes
No
Birthdate Verified
Yes
No
Registration Fees:
Signature of Parent or Guardian
Player Fee Activity Fee
X
Other ___________________
Received by
Date
Address City Phone: Home
State
Zip Bus.
Total
$
Cash Check No.
League Name
Age Group
FOR LEAGUE USE ONLY TRANSFER NEW REREGISTRATION CHANGE/CORRECTION
Div. National Assoication of the United States Soccer Federation (USSF) Affiliated with the Federation Internationale de Football Association (FIFA)
Club/Team Name(s)
Recreational = R Select = S
Last Name
First Name
ID#
Init.
Address
City
State
Zip Code
Area Code
Telephone Number
Father's Name
Male = M Female = F
Month Day Year Birthdate
Occupation
Player = P Coach = C
Coach's License level
Bus. Phone Optional
Mother's Name
Occupation
Bus. Phone Optional
List any medical problem or prohibition player has Person to notify in emergency
Telephone
Doctor to notify in emergency Number prior seasons played
Last Team
Height
Weight
Telephone Date and Year of Last Season
Last League School
Grade
UNIFORM SIZE XS
S
M
Age
Adult
Youth L
XL
XS
S
M
L
XL
SHIRTS: SHORTS:
Other Children From Family Presently In League
Age Age Age
SOCKS:
Age
IMPORTANT I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of US Youth Soccer, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the US Youth Soccer accepting the registrant for its soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. Name
PARENTAL SUPPORT We ask for active participation of all parents in our program. Check area(s) in which you would be willing to help. Coach Committee
Parent/Legal Guardian (please print)
Signature
Date
Asst. Coach Team Manager Team Parent
Referee Fund Raising Clerical
Special Projects Field Preparation
Reporter Newsletter
Board Member
Concessions
Publicity
Donor
Other
CONSENT FOR MEDICAL TREATMENT (MINOR) As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
OFFICIAL USE ONLY
Picture Received
Yes
No
Birthdate Verified
Yes
No
Registration Fees:
Signature of Parent or Guardian
Player Fee Activity Fee
X
Other ___________________
Received by
Date
Address City Phone: Home
State
Zip Bus.
Total
$
Cash Check No.
